“Concern was expressed as to the adequacy of the monitoring and review of blood sugar…”
Dated 6 Feb 2017, from the coroner for Manchester North. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 3 Apr 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated6 Feb 2017
- Deadline3 Apr 2017
- Published on judiciary.uk26 Feb 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social CareNamed in the report as “Department of Health” | Response publishedPublished on judiciary.uk in February 2017. |
| Northern Care Alliance NHS Foundation TrustNamed in the report as “Salford Royal NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 3 Apr 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
- 1. Concern was expressed as to the adequacy of the monitoring and review of blood sugar levels/data generated following the initial use of the pump provided by the Salford Royal Trust which provided Natalie’s equipment and had been caring for her over many years. More particularly trends were not analysed. Whilst noting that the introduction of insulin pump therapy was deemed an evolutionary process no formal Pump Agreement was in place at the time although such Agreements have now been implemented 2. From the evidence given by the expert Consultant it would appear that the level of support for insulin pump users nationally is variable. Whether the need for consistency and minimum standards should be addressed by Regional Centres of Excellence would be a matter for the Department to consider.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2017-0030
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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